Fall, Winter, & Spring Weekend Retreats (You may select multiple retreats)

Whiteout Retreat, February 16-18, 2018 - With Kalahari $125 RETREAT FULL, WAITING LIST
Whiteout Retreat, February 16-18, 2018 - With Kalahari $125 RETREAT FULL, WAITING LIST

Camper Personal Information

Registration Contact Information
(registration and billing confirmation email will be sent here)

Church Information

Camp Roommates (Maximum of 3)
Roommate 1:
Roommate 2:
Roommate 3:
I am coming with a group leader: Yes No
Leader Name:

Camper Allergies/Medications/Conditions Information
Is your child allergic to:
Nuts Dairy Products Bee Sting
Hay/straw Drug:
Does your child have any life-threatening allergies?
Is your child bringing any medication with him/her?
Does your child have any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?
Has your child ever had:
Seizures Celiac's Disease Homesickness
Diabetes Asthma
Does your child use an inhaler? No Yes
Date of Last Tetanus Shot:
Treatment Information
This information will help our camp nurse provide the proper care for your child if
they have any of the following symptoms. You may mark more than one item.
For headache give my child:
Tylenol Ibuprofen
For fever give my child:
Tylenol Ibuprofen
Parents will be contacted if the child has a fever >100.4 for 24 hours or if it appears infectious.
For nausea or upset stomach give my child:
Maalox Emetrol Tums Gingerale
For minor sore throat or cough without a fever give my child:
Chloraceptic spray Tylenol throat lozenges
salt-water gargle Robitussin DayQuil NyQuil
For stuff/runny nose give my child:
Sudafed Benadryl
Zyrtec Claritin
For constipation give my child:
Colace (stool softener) Metamucil Milk of Magnesia
For diarrhea please give my child:
Clear liquids only Kaopectate
Imodium AD Pepto-Bismol
Parents will be notified if symptoms persist or appear to be infectious.
For minor cuts and abrasions
it is ok to use antibiotic
ointment along with normal
cleansing and covering of
For insect bits or bee stings with localized reaction, my child may be given Benadryl.
Please note any other health care treatments that may be needed for your child while he/she is at camp.
A full time nurse is on duty at each camp. Beulah Beach's medical payments insurance for campers
begins where yours terminates. In the event that you have no other insurance, the camp insurance will provide
coverage up to policy limits subject to policy provisions.
Insurance Company
Insurance Policy #
Please give us the name of the legal guardian
Relationship to Camper:
Father Mother Guardian
Please list all emergency contact names & numbers in call order:

Agreements and Disclaimers
* In case of an emergency, I authorize Beulah Beach to call a doctor or practitioner to administer
medical aid treatment for my child at any time when they believe an emergency exists. In addition,
I give parental permission for treatment and/or admission to a medical facility.
* I have read Beulah Beach's Registration Policy.
* I authorize Beulah Beach to charge my credit card for fees related to this registration.
* I Agree to the following Release & Indemnity Agreement:

In signing this document, I hereby certify that I give permission to my son or daughter to participate
in the camping program at Beulah Beach Camp & Retreat Center. I also give permission for my son or
daughter to be transported in vehicles for camp approved transportation and activities. I also authorize
Beulah Beach Camp & Retreat Center to use photographs, video, and audio clips, including those of my son
or daughter in, in camp publicity.

In consideration of permission granted the herein named individuals to participate in camping activities,
we herby release and covenant with Beulah Beach Camp & Retreat Center that we will never, individually or
as legal guardians of said individuals, institute any action at law or in equity for any personal injuries,
or injuries to property, real or personal, accused by, or arising out of camping and other related activities
sponsored by Beulah Beach Camp & Retreat Center, its successors and legal representatives; we further agree
to indemnify and hold Beulah Beach Camp & Retreat Center harmless against any and all cost, damages and
expenses which may be incurred by them as a result of any lawsuit we might file against them. We under-
stand and acknowledge that camp activities have inherent dangers that no amount of care, caution,
instruction or expertise can eliminate and we and the participant expressly and voluntarily assume all
risk of personal injury sustained while participating in aforementioned activities whether or not caused
by the negligence of the released parties.

Parent Signature 1*: 02/20/2018
Parent Signature 2: 02/20/2018

(both signatures required when applicable)

Discounts and Credits
(summer resident camps only)
Church Voucher: Voucher Amount: $

Requirements: I acknowledge that I have a completed church voucher for the above amount in my possession. I understand that if it is not received by Beulah Beach within 7 days from the date you send this registration to Beulah Beach, my credit card will be charged the amount above and the voucher will not be honored.

Payment Information
Late Fee Schedule (Summer Camps Only)

Two weeks before your camp starts or 8-14 days prior to camp start date: add $20 late fee
Week before camp starts or 0-7 days prior to camp start date: call for availability, add $40 late fee.

Late fees are not calculated in the total below, however they will be added if applicable. Thanks.

Registration Amount: $ This is the total amount of registration due to attend.
Zone/Track Extra Charges: $ Additional Charges for eXtreme Zone or Splash "track" charges.
Discount Amount: $ This is the total discounts & credits applied.
Total being charged now: $ Total being charged today.
Amount Owed: $ This amount owed AFTER this payment.

On the following page your billing information will be collected for the above stated "Total being charged now"
Please do NOT use the back button on your browser during the registration process